During the month before Gabriel Trujillo died, medical professionals could not determine whether the bruises, scrapes and a fracture on his body were there by accident or a result of abuse.

Weeks later, emergency crews rushed the 4-year-old — emaciated, covered in bruises and what appeared to be cigarette burns — to the hospital. He died days later from blunt-force injuries to his head and neck.

Gabriel fits into one of the most difficult age groups for determining whether injuries are caused by accidents or abuse, said Dr. Desmond Runyan, executive director of the Kempe Center for the Prevention and Treatment of Child Abuse and Neglect.

Once a child becomes mobile and is not completely dependent on caregivers, it becomes increasingly difficult to determine whether the child got a bruise from abuse or from normal trips and bumps, Runyan said. Until children are closer to 6 or 7 years old, they are less likely to recognize the injury as abuse and may not be able to reveal details about what happened, because of a lack of understanding or fear of having done something wrong themselves.

"It's a tough art to try and sort out intentional versus unintentional injuries once the kids are old enough to walk," Runyan said. "Once the children are older, then they understand that other people can be bad and everything that happens to them isn't their fault."

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Gabriel and his two older siblings were in the care of their maternal grandmother, Doris Becky Trujillo, 60, at the time of his death.

Gabriel's paternal grandmother, Elizabeth Trujillo, said she and her family became concerned about the boy when they saw photos of him with large bruises. On Feb. 7, she called the Adams County Human Services Department and was told to call Commerce City police, who went to the boy's home.

The next day, officers told Elizabeth Trujillo everything appeared normal at the home.

On Feb. 14, emergency crews were called to Doris Becky Trujillo's Commerce City home, where they found her holding Gabriel's naked body, according to an Adams County court document that was used to justify holding Trujillo in jail without bail.

Gabriel's body temperature was around 89 degrees. Trujillo told police that she punished the child by making him stand naked outside in the cold.

Medical professionals at Children's Hospital Colorado in Aurora, where Gabriel was taken, reported that he had "catastrophic head injuries," including "evidence of old cranial bleeding." Gabriel also appeared malnourished and had multiple contusions and hypothermia, the court document obtained by 9News said.

Gabriel died four days later.

Trujillo has been charged with first-degree murder.

On Saturday, Lana Roberts, 48, who was living with Doris Becky Trujillo when Gabriel died, was charged with one count of child abuse resulting in death.

According to the court document, Trujillo told investigators Gabriel fell off a 2-foot-high chair. Injuries more severe than the falls caregivers describe are a red flag for medical personnel looking for abuse, Runyan said. Short falls, such as falling off beds or chairs, seldom cause depressed or "eggshell" skull fractures.

Bruises in fleshy parts of the child's body, such as their abdomen, thigh or buttocks, also are concerning, as they take more force to cause, Runyan said.

Injuries to about 10 percent of the children treated a typical hospital burn unit are caused by intentional action, Runyan said.

Determining when injuries are caused by abuse also requires medical professionals to find a delicate balance between obtaining information from children while trying not to alienate parents trying to get care for their children, Runyan said.

Fewer than 10 percent of children hospitalized with injuries are victims of physical abuse, Runyan said.

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